Provider Demographics
NPI:1851836365
Name:DVORAK, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:DVORAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 VARSITY DR
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120-8176
Mailing Address - Country:US
Mailing Address - Phone:847-741-2600
Mailing Address - Fax:847-741-3248
Practice Address - Street 1:675 VARSITY DR
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-8176
Practice Address - Country:US
Practice Address - Phone:847-741-2600
Practice Address - Fax:847-741-3248
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.011570101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)